Near drowning: fresh water, sea Near drowning: fresh water, sea water or cold water – is there any water or cold water – is there any

difference?difference?

Goran PopićGoran Popić

Pulmonary Division, Dpt of Medicine, Pulmonary Division, Dpt of Medicine, General Hospital, PulaGeneral Hospital, Pula

Near drowning is Near drowning is the survival of a drowning event the survival of a drowning event

and can lead to and can lead to serious secondary complicationsserious secondary complications

including death.including death.

Near drowning salvage at the moment of Near drowning salvage at the moment of birth:birth:

At birth the airways are filled with fluid.At birth the airways are filled with fluid. Release of compression after passage through Release of compression after passage through

the birth canal causes air to be sucked in.the birth canal causes air to be sucked in. Large force is necessary during the first Large force is necessary during the first

inspiration to overcome the surface tension.inspiration to overcome the surface tension. After that – large quantities of surfactant are After that – large quantities of surfactant are

released by the pneumocytes II.released by the pneumocytes II.

The principal physiologic consequences of The principal physiologic consequences of immersion are persistent immersion are persistent hypoxemiahypoxemia and and resultant ischemic resultant ischemic acidosisacidosis. . A surprising degree of hypoxia can exsist A surprising degree of hypoxia can exsist without clinical signs.without clinical signs.

Near drowning causes lung tissue hypoxia and Near drowning causes lung tissue hypoxia and sequential changes as in:sequential changes as in:

high altitude pulmonary edemahigh altitude pulmonary edema ““mechanical” (strangulation etc.) mechanical” (strangulation etc.)

causes of pulmonary edemacauses of pulmonary edema avalanche victimsavalanche victims acute lung injury / ARDSacute lung injury / ARDS

QuestionQuestion:: Near drowning in fresh water Near drowning in fresh water (hypotonic) ... and the meaning of (hypotonic) ... and the meaning of →→

surfactant destruction?surfactant destruction? serum electrolyte imbalances?serum electrolyte imbalances? hemolysis?hemolysis?

AnswerAnswer:: UNIMPORTANT ! UNIMPORTANT !

(in terms of management)(in terms of management)

QuestionQuestion:: Near drowning in sea water Near drowning in sea water (hyperosmolar) ... and the meaning of (hyperosmolar) ... and the meaning of →→

fluid exudation into the alveoli?fluid exudation into the alveoli? surfactant washout?surfactant washout? hyperosmolar injury of the epithelium?hyperosmolar injury of the epithelium? serum electrolytic changes?serum electrolytic changes?

AnswerAnswer:: UNIMPORTANT ! UNIMPORTANT !

(in terms of management)(in terms of management)

QuestionQuestion:: Near drowning in cold water? Near drowning in cold water?

Definition: cold water = less than 21Definition: cold water = less than 21˚ C˚ C

AnswersAnswers::- BadBad:: difficult swimming (muscular difficult swimming (muscular

weakness), impaired judgement, core weakness), impaired judgement, core hypothermia and VFhypothermia and VF

- GoodGood:: hypothermia and neuroprotection, hypothermia and neuroprotection, the mammalian diving reflexthe mammalian diving reflex

The mammalian diving reflex is triggered by The mammalian diving reflex is triggered by cold water contacting the face (ophthalmic cold water contacting the face (ophthalmic division of the trigeminal nerve) and causes:division of the trigeminal nerve) and causes:

ApneaApnea BradycardiaBradycardia Peripheral vasoconstrictionPeripheral vasoconstriction Thoracic blood shift and filling up alveoli Thoracic blood shift and filling up alveoli

with plasmawith plasma

Near drowning in cold water, prognosis:Near drowning in cold water, prognosis:

Age of victim – the younger the betterAge of victim – the younger the better Water temperature – the colder the betterWater temperature – the colder the better Victim’s struggle – the more the worseVictim’s struggle – the more the worse

Note:Note: if a person has been under water for if a person has been under water for LESS THAN ONE HOUR, full resuscitative LESS THAN ONE HOUR, full resuscitative efforts should be employedefforts should be employed

General Hospital, Pula: 46 consecutive cases of near General Hospital, Pula: 46 consecutive cases of near drowning victims, retrospective review:drowning victims, retrospective review:

78% males78% males 75% swimmers75% swimmers 72% tourists72% tourists In some cases - incapatitation arising from alcohol, In some cases - incapatitation arising from alcohol,

heart attack, seizure, strokeheart attack, seizure, stroke In others – barotrauma or blackout on ascent from In others – barotrauma or blackout on ascent from

deep divedeep dive No signs of atelectasis seen on the x-raysNo signs of atelectasis seen on the x-rays Two deaths in hospitalTwo deaths in hospital

Treatment of near drowning victims, some Treatment of near drowning victims, some important points:important points:

Immediate on site CPR is the key to increase the Immediate on site CPR is the key to increase the chance of survival.chance of survival.

DO NOT DO any specific maneuvers (Heimlich) to DO NOT DO any specific maneuvers (Heimlich) to expel water from the lungs.expel water from the lungs.

ED observation for 8 hours to screen for those ED observation for 8 hours to screen for those requiring hospital admission.requiring hospital admission.

Arterial blood gas analysis and chest x-rays are Arterial blood gas analysis and chest x-rays are the most reliable parameters.the most reliable parameters.

Warning of any pyrexial illness after discharge Warning of any pyrexial illness after discharge (secondary pulmonary infection).(secondary pulmonary infection).